Greater Lincolnshire

Concerns summary Contradictory evidence regarding care home staffing levels and compliance with training/supervision regulations, coupled with unaddressed witness non-attendance, raises concerns about adequate care provision.

Concerns summary A notorious accident hotspot lacked essential traffic calming measures, including reduced speed limits and double white lines, contributing to numerous near misses and non-fatal collisions.

Concerns summary Concerns exist regarding emergency medical service protocols: specifically, the lack of a mechanism for escalating low-priority calls (C3) to high-priority (C2) when response times are exceeded, and inadequate contact with NHS 111 for unassessed C3 calls.

Concerns summary A dangerous and confusing staggered junction, identified as an accident blackspot with multiple fatalities, poses an ongoing risk to road users due to its layout and lack of traffic calming measures.

Concerns summary A fatal fire resulted from a vapour leak in a relatively new domestic fridge, highlighting a potential widespread safety risk with similar units in circulation.

Concerns summary Concerns include the failure to dispatch first responders, frequent exceeding of ambulance response times, and a problematic system that cancels initial waiting times upon call regrading.

Concerns summary A critical communication breakdown occurred between paramedics pre-alerting the hospital and the hospital's readiness for a critically ill patient, raising significant concerns for future emergency admissions.

Concerns summary There is a significant lack of HSE guidance for historic and heritage equipment, much of which is unguarded and dangerous, creating a high probability of further deaths.

Concerns summary The national speed limit is too high for a bridge with restricted visibility and a height limitation requiring high-sided vehicles to use the center, exacerbated by a lack of priority signage.

Concerns summary There was a significant delay in submitting an incident review report, families did not receive an apology, and none of the recommended action plan items were implemented.

Concerns summary The serious incident analysis report was significantly delayed in being received by the coroner's office, hindering timely review and learning.

Concerns summary Concerns about the lack of continuity and appropriateness of GP medical staff, and whether vital recommendations from a 2015 safeguarding report have been fully implemented.

Concerns summary The junction design is "challenging" and dangerous, evidenced by a history of fatal collisions and observed "near misses." There were also significant delays for HGVs attempting to turn safely.

Concerns summary Unregulated, non-standard anti-glare visors significantly obscured driver vision due to extremely low light transmission. A lack of legislation and British Standard certification for these devices poses a safety risk.

Concerns summary Biopsy reports lacked sufficient space for consultants to fully complete their findings, resulting in incomplete and potentially inadequate medical documentation.

Concerns summary A staggered junction, despite meeting design specifications, has a concerning history of multiple fatalities and injury-producing collisions, suggesting inherent safety issues with the junction's design.

Concerns summary Dispensing pharmacists continue a practice, contrary to professional advice, of snipping tablets from unit dose packs into multi-dose compliance aids, risking drug integrity and patient safety.

Concerns summary Unlicensed firearms are often insecurely stored, available for impulsive use. Publicising that surrendering such weapons usually avoids prosecution might encourage their removal.

Concerns summary Specific synthetic cannabinoid receptor agonists (5F AKB-48, 5F PB-22) are not controlled substances, and the deceased's chronic misuse was not reported to the DVLA.

Concerns summary Police failed to communicate critical information about the deceased's recent suicide threat to arresting officers and custody staff, resulting in an incomplete risk assessment upon release.

Concerns summary Significant and unacceptable delays in ambulance dispatch occurred for an unconscious patient with a serious head injury, potentially prejudicing the outcome.

Concerns summary Detainees were locked in rooms overnight against recommendations, staff lacked robust detention awareness and refresher training, and crucial information like removal directions was not shared.

Concerns summary Existing guidance for co-prescribing Lisinopril and Spironolactone may not sufficiently highlight the risks of renal deterioration and hyperkalaemia, indicating a need for more caution and a holistic patient view.

Concerns summary Product information for SSRI drugs fails to adequately inform prescribers about potential adverse pharmacokinetic interactions with cocaine and other illicit substances, or to advise patients to seek caution.

Concerns summary Inadequate communication channels failed to inform the Fire and Rescue Service about high-risk home oxygen users who smoked, preventing assessment for crucial safety equipment like smoke alarms and flame-retardant bedding.